What you need to know about Madagascar plague outbreak

An outbreak of plague in Madagascar has killed scores and infected at least 1,300 others, according to a report published by the World Health Organisation (WHO). The death toll is forecast to rise in the next few days in a country where plague is a seasonal occurrence but where this time the spread has been further than usual. However, authorities say the risks of it spreading internationally are low.

Plague reports have a morbid hold over humans psyche, given the many times epidemics have threatened humanity’s survival. The most infamous case was the “Black Death” epidemics that ravaged the Eurasian continent in the mid-fourteenth century. The pandemic killed up to half of Europeans, according to this analysis by the BBC health editor.

Here’s what you need to know about the outbreak.

Where did it start?

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The outbreak started on August 27 after an unnamed 31-year old man died while travelling by shared public taxi to Toamasina, a port city in east Madagascar. On August 23, the man had visited Madagascar’s Ankazobe District in the Central Highlands – a historic plague hotspot – where he developed symptoms mistaken for malaria.

His death was not initially linked to the plague. No precautions were taken for his burial. From the moment he contracted the disease until his death, the man came into contact with 31 people. Four of them subsequently died.

The man’s journey took him through Antananarivo, Madagascar’s capital, which is now the area of the country most affected by the disease.

The outbreak was detected on September 11 after the death of a 47 year-old woman from Antananarivo. She was admitted to hospital for respiratory failure caused by pulmonary plague.

What’s different?

Plague outbreaks are a seasonal occurrence in Madagascar, the African island nation of roughly 24 million people. But these outbreaks are different for several reasons: they began earlier than usual; they feature a higher incidence of the lethal pneumonic plague strain; and they are affecting highly populated areas of Madagascar, including its two largest cities – Antananarivo and Toamasina.

What is the plague?

The plague is caused by the Yersinia pestis bacteria. There are three variants of the disease, depending on the route of infection: pneumonic (through the lungs), bubonic (through the lymph nodes), and septicemic (through the blood).

One of the most preoccupying and unusual aspects of this outbreak is that 67 percent of cases are due to the most virulent strain of the disease – the pneumonic, or pulmonary, plague.

This variant is almost 100 percent lethal unless treated early. It attacks the victim’s lungs. It is highly infectious and usually develops following an initial bubonic or septicemic plague infection, but can also spread from human to human through airborne transmission. However, recovery rates are high if the disease is spotted and treated within the first 24 hours.

Pulmonary plague symptoms start manifesting within one to three days and may include fevers, headaches, chest pains, shortness of breath, and (usually bloody) coughs.

Outbreak still worries

The WHO reports that the number of new cases has continued to fall across all active areas of the country over the past two weeks. However, the severe nature of the disease and its risk of contagion mean “the overall risk at the national level is considered very high”.

The organisation says it is working with Madagascar’s Ministry of Public Health and other Malagasy institutions “to monitor and respond to the outbreak of plague.”

The government initially told journalists it had the situation under control, according to Rondro Ramamonjisoa, deputy editor-in-chief for national newspaper L’Express de Madagascar.

“A week of panic,” Ramamonjisoa told WikiTribune, ensued after a visiting basketball coach from Seychelles died from the pneumonic plague on September 27 in Antananarivo. On October 11, Malagasy President Hery Rajaonarimam­pianina broke his silence to urge Malagasies to remain calm, according to the Express (link in French).

“The government took some time to decide, but once they did everything started moving,” says Ramamonjisoa.

To stall the outbreak, the government temporarily shut down public institutions, including schools and two universities. It also called off public gatherings, The Washington Post says quoting local media reports.

On October 6, the WHO said it delivered almost 1.2 million doses of antibiotics and released $1.5 million in emergency funds to fight the spread of the disease in Madagascar.

The disease has struck people of all ages. On October 31,  the Express (link in French) reported that the death toll rose to 128 following the death of a child at a hospital in Antananarivo over the weekend.

The newspaper also reported that a man infected with the disease escaped quarantine on October 26, raising fears he might infect others. According to the newspaper, Madagascar’s Public Health Minister said the man was “public danger number one”. WikiTribune has been unable to independently corroborate these reports.

Alarm bells elsewhere

Plague reports have set off alarm bells around another nine southeastern African countries and overseas territories. Comoros, Ethiopia, Kenya, Mauritius, Mozambique, La Réunion (France), Seychelles, South Africa, and Tanzania have all been placed on alert due to their trade and travel links to Madagascar, according to the WHO report.

While the WHO report describes the risk of regional spread is “moderate,” it says the risk of international contamination is “low.” This is mainly due to the disease’s short incubation period and screening measures put in place by the WHO and Madagascar’s Ministry of Public Health.

However, strict security measures are in place in Malagasy transport hubs, including ports and airports.

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